- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,623.41 / $10,471.29
| Facility | | $1,202.26 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $588.84 / $1,230.27
| Professional | | $478.63 | $588.84 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $870.96
| Professional | | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $741.31 / $1,230.27
| Professional | | $524.81 | $741.31 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,949.84 / $26,302.68
| Facility | | $602.56 | $1,949.84 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $676.08 / $4,365.16
| Professional | | $575.44 | $676.08 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,981.07 / $8,912.51
| Facility | | $1,995.26 | $3,981.07 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $645.65 / $912.01
| Professional | | $575.44 | $645.65 | $912.01 |